tag:theconversation.com,2011:/africa/topics/pre-exposure-prophylaxis-23617/articlesPre-exposure prophylaxis – The Conversation2022-12-18T13:16:47Ztag:theconversation.com,2011:article/1902252022-12-18T13:16:47Z2022-12-18T13:16:47ZLong-acting injectable PrEP is a big step forward in HIV prevention<figure><img src="https://images.theconversation.com/files/501164/original/file-20221214-16278-cj9xs2.jpg?ixlib=rb-1.1.0&rect=66%2C473%2C6908%2C4429&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The HIV prevention drug cabotegravir, which is delivery by injection every eight weeks, is not yet available in Canada.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>One year ago, <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-injectable-treatment-hiv-pre-exposure-prevention">the United States approved a new injectable drug that prevents HIV</a>. </p>
<p><a href="https://doi.org/10.1056/NEJMoa2101016">After successful clinical trials</a>, long-acting cabotegravir was found to be almost 100 per cent effective at preventing HIV. It was approved in the U.S. on Dec. 20, 2021, for use as HIV pre-exposure prophylaxis (PrEP). This approval means that eligible individuals can now receive this medication every eight weeks to prevent sexually-acquired HIV infection.</p>
<p>However this new drug, which would help address some of the <a href="https://www.cdc.gov/nchhstp/newsroom/fact-sheets/hiv/state-of-the-hiv-epidemic-factsheet.html#gains-challenges">ongoing challenges with HIV prevention</a> for those who remain at high risk, is still not available in Canada.</p>
<h2>HIV in Canada</h2>
<p>The number of new HIV infections has not changed much over the past couple of decades and <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90.html">approximately 13 per cent of people living with HIV in Canada are undiagnosed</a>. This demonstrates the need for more HIV prevention strategies. </p>
<p>While long-acting injectable PrEP is new, oral PrEP — <a href="https://www.catie.ca/pre-exposure-prophylaxis-prep-0">a pill taken either daily or around sexual activity</a> — was approved in the U.S. back in 2012. <a href="https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2017-43/ccdr-volume-43-12-december-7-2017/hiv-pre-exposure-prophylaxis-use-canada.html">Canada only approved oral PrEP in 2016</a>. And we are once again falling behind the U.S. on making injectable PrEP available here.</p>
<p><a href="https://doi.org/10.1503/cmaj.220645">Oral PrEP already reduces the risk of HIV by almost 100 per cent</a> when taken consistently, but recent clinical trials show that injectable PrEP is even more effective. The main advantage of injectable PrEP is that going for injections every two months is a lot easier to remember than taking pills every day, or taking pills before and after sexual activity. The switch from oral pills to injectable shots means that individuals can more easily maintain adherence, which impacts the overall effectiveness of PrEP as HIV prevention.</p>
<figure class="align-center ">
<img alt="Close-up of a hand with four blue caplets in the palm." src="https://images.theconversation.com/files/500660/original/file-20221213-4932-7g9lp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500660/original/file-20221213-4932-7g9lp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500660/original/file-20221213-4932-7g9lp5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500660/original/file-20221213-4932-7g9lp5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500660/original/file-20221213-4932-7g9lp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=533&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500660/original/file-20221213-4932-7g9lp5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=533&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500660/original/file-20221213-4932-7g9lp5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=533&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Oral PrEP reduces the risk of HIV infection, but injectable PrEP would offer a long-acting option.</span>
<span class="attribution"><span class="source">(AP Photo/Jeff Chiu)</span></span>
</figcaption>
</figure>
<p>Although some people might prefer pills to shots for various reasons, injectable PrEP provides another option, and <a href="https://doi.org/10.1038/s41598-021-01634-3">people like having different HIV prevention options available to them</a>. At the individual level, injectables mean more choices. At the population level, more choices mean more prevention because different people might be willing to use different kinds of PrEP to suit their needs.</p>
<p>Contraception research has also demonstrated the importance of expanding people’s medication options. <a href="https://my.clevelandclinic.org/health/drugs/4086-depo-provera%C2%AE-birth-control-shot#:%7E:text=Commonly%20referred%20to%20as%20the,taken%20according%20to%20the%20schedule.">Injectable contraceptives</a> highlight how this technology improves both sexual and reproductive health.</p>
<p><a href="https://doi.org/10.1093/cid/cit085">Oral PrEP is often compared with the birth control pill</a>. There is a need to better understand how new injectable options for both contraception and HIV prevention affect adherence, access and the relationships of those who use them. </p>
<p>Both injectable and oral PrEP are safe and highly effective and they each have very few side-effects. Injectable PrEP has mild injection site reactions, including swelling, redness and pain.</p>
<p>There are also <a href="https://blog.catie.ca/2022/03/25/the-future-of-prep-is-now/">several other new HIV PrEP options</a> that are still being studied in clinical trials, including exciting long-acting oral, injectable, implantable and infusion options that are administered at different time intervals and could fit the different schedules and preferences of people interested in HIV prevention.</p>
<h2>Preparing for prevention</h2>
<p>We can be ready for these new developments by learning from our past experiences with the approval and implementation of previous HIV prevention strategies, like oral PrEP. Some individuals and communities still face barriers to PrEP, <a href="https://www.catie.ca/prevention-in-focus/overcoming-barriers-to-prep-program-models-using-diverse-settings-and-providers">like access to health-care providers who are knowledgeable about it</a>, and these barriers can perpetuate health inequalities.</p>
<p>Our research project, <a href="https://www.cbrc.net/futureofprep">The Future of PrEP is Now</a>, focuses specifically on community readiness for long-acting injectable PrEP because it has the potential to help overcome previous barriers to PrEP. Oral PrEP can still be inaccessible, expensive and stigmatized for many people in Canada and the one-pill-a-day adherence can be especially challenging. </p>
<p>Communities of Two-Spirit, gay, bisexual, queer and other men who have sex with men (2SGBQM) are <a href="https://www.catie.ca/the-epidemiology-of-hiv-in-canada">still disproportionately affected by HIV, and HIV rates are not declining in Canada</a>. 2SGBQM are also under-reached by existing PrEP programs, especially those who are Indigenous, Black, people of colour, rural, people who use substances, transgender and non-binary.</p>
<p>In our research, we talk to members of under-reached communities of 2SGBQM as well as the health-care providers who serve them to:</p>
<ol>
<li>learn their preferences regarding future long-acting injectable PrEP options</li>
<li>assess the feasibility of various models of delivering injectable PrEP </li>
<li>design a national study of injectable PrEP that responds to the needs and priorities of individuals already experiencing barriers to oral PrEP.</li>
</ol>
<p>In a recent public webinar, we asked <a href="https://www.catie.ca/prep-where-are-we-going">“where are we going?”</a> with PrEP as we plan for a long-acting injectable option to become available in Canada in the near future. We want to ensure that when this new treatment is approved, long-acting PrEP is quickly available and as equally accessible as oral PrEP to those who will benefit from it the most. Raising awareness and building support for this new HIV prevention strategy will help meet those goals.</p><img src="https://counter.theconversation.com/content/190225/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Montess receives funding from the Canadian Institutes of Health Research, Mitacs, the Social Sciences and Humanities Research Council, and the Michael Smith Foundation for Health Research. He is affiliated with the University of Victoria. </span></em></p><p class="fine-print"><em><span>Darrell Tan receives funding from the Canada Research Chairs program, the Canadian Institutes of Health Research, the CIHR Canadian HIV Trials Network, the Public Health Agency of Canada, the Canadian Foundation for AIDS Research, and the Ontario HIV Treatment Network. He is affiliated with St. Michael's Hospital and the University of Toronto. </span></em></p><p class="fine-print"><em><span>Nathan John Lachowsky receives funding from the Canadian Institutes of Health Research, Social Sciences and Humanities Research Council, MITACS, Public Health Agency of Canada, Canadian Blood Services, Canadian Foundation for AIDS Research, Michael Smith Health Research British Columbia, Government of British Columbia, Vancouver Foundation, and Victoria Foundation. He is affiliated with the Community Based Research Centre.</span></em></p>The next step in HIV prevention — long-acting injectable pre-exposure prophylaxis (PrEP) — is not yet available in Canada, a year after its approval in the U.S.Michael Montess, Postdoctoral Associate, Rotman Institute of Philosophy, Western UniversityDarrell Tan, Clinician-Scientist, St. Michael’s Hospital; Associate Professor, Faculty of Medicine, University of TorontoNathan John Lachowsky, Associate Professor, Public Health & Social Policy; Special Advisor Health Research, Office of the Vice-President Research and Innovation, University of VictoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1903172022-09-13T12:33:27Z2022-09-13T12:33:27ZFree preventive care under the ACA is under threat again – a ruling exempting PrEP from insurance coverage may extend nationwide and to other health services<figure><img src="https://images.theconversation.com/files/484101/original/file-20220912-5769-hqsuwm.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C683&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">PrEP is almost 100% effective in preventing HIV infection when taken as directed.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/thembelani-sibanda-shows-the-pre-exposure-prophylaxis-an-news-photo/888296568">The Times/Gallo Images via Getty Images Editorial</a></span></figcaption></figure><p>Many Americans breathed a sigh of relief when the Supreme Court left the Affordable Care Act in place following the law’s <a href="https://www.supremecourt.gov/opinions/20pdf/19-840_6jfm.pdf">third major legal challenge</a> in June 2021. This decision left <a href="https://source.wustl.edu/2017/02/americans-divided-on-obamacare-repeal-poll-finds/">widely supported policies</a> in place, like ensuring coverage <a href="https://www.healthcare.gov/coverage/pre-existing-conditions/">regardless of preexisting conditions</a>, coverage for <a href="https://www.healthcare.gov/young-adults/children-under-26/">dependents up to age 26</a> on their parents’ plan, and removal of <a href="https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/">annual and lifetime benefit limits</a>.</p>
<p>But the hits keep coming. One of the most popular benefits offered by the ACA, <a href="https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/">free preventive care</a>, is under legal threat again by <a href="https://www.vox.com/policy-and-politics/2022/9/7/23341076/obamacare-reed-oconnor-prep-supreme-court-braidwood-becerra-affordable-care-act">Braidwood Management v. Becerra</a> – originally Kelley v. Becerra. The Braidwood plaintiffs are a mix of individuals and business owners who object to purchasing insurance that covers preexposure prophylaxis – or PrEP – a medicine that is <a href="https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html">almost 100% effective</a> in preventing HIV infection. One of the plaintiffs claimed that PrEP “facilitates and encourages homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman” and that his religious beliefs prevent him from providing insurance that covers PrEP.</p>
<p>On Sep. 7, 2022, Texas Judge Reed O’Connor issued a <a href="https://affordablecareactlitigation.files.wordpress.com/2022/09/gov.uscourts.txnd_.330381.92.0_1.pdf">ruling</a> that the requirement for insurance plans to cover PrEP violated the religious freedom of the plaintiffs. He also ruled that the ACA overstepped in delegating decisions about cost-sharing for preventive care to the U.S. Preventive Services Task Force. Who this ruling will ultimately affect and whether it will eventually get rid of the requirement to fully cover other preventive care, like free flu shots and cancer screening, has <a href="https://www.healthaffairs.org/content/forefront/court-holds-key-aca-preventive-services-requirements-unconstitutional">yet to be confirmed</a>.</p>
<p>We are public health researchers at <a href="https://www.bu.edu/sph/profile/paul-shafer/">Boston University</a> and <a href="https://sph.tulane.edu/sbps/kristefer-stojanovski-phd-mph">Tulane University</a> who study health insurance, prevention and sexual health. With this policy now in jeopardy, prevention and the push for health equity in the U.S. stand to take a big step backward.</p>
<h2>The ACA and preventive care</h2>
<p><a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2713">Section 2713</a> of the ACA requires insurers to offer <a href="https://www.healthcare.gov/coverage/preventive-care-benefits/">full coverage of preventive services</a> that are endorsed by one of three federal groups: the U.S. Preventive Services Task Force (with an A or B rating), the Advisory Committee on Immunization Practices and the Health Resources and Services Administration. If they recommend the procedure or intervention as important preventive care, then you shouldn’t have to pay anything out of pocket. For example, <a href="https://www.congress.gov/bill/116th-congress/house-bill/748/">the CARES Act</a> used this provision to ensure COVID-19 vaccines would be free for many Americans.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Healthcare provider examining child in exam room." src="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418993/original/file-20210901-13-wnh1xo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Affordable Care Act significantly reduced the costs of well-child visits since it was instated.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/girl-having-checkup-in-doctors-office-royalty-free-image/153337724">John Fedele/The Image Bank via Getty Images</a></span>
</figcaption>
</figure>
<p>PrEP received an <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis">A rating</a> in June 2019, paving the way for both PrEP and related services like clinic visits and lab tests to be covered at no cost for millions of people. </p>
<p>Though Section 2713 of the ACA <a href="https://doi.org/10.1016/j.ypmed.2021.106690">doesn’t work perfectly</a>, sometimes leaving patients frustrated by <a href="https://www.washingtonpost.com/national/health-science/getting-charged-for-free-preventive-care/2014/01/17/98fbd1fa-7ec2-11e3-95c6-0a7aa80874bc_story.html">unexpected bills</a>, it has made a huge difference in reducing costs for services like <a href="https://doi.org/10.1001/jamanetworkopen.2021.1248">well-child visits</a> and <a href="https://doi.org/10.1097/MLR.0000000000000610">mammograms</a>, just to name a few.</p>
<h2>The legal arguments</h2>
<p>The latest case rested on <a href="https://theconversation.com/the-next-attack-on-the-affordable-care-act-may-cost-you-free-preventive-health-care-166087">legal technicalities</a> that have nothing to do with PrEP, but rather whether the U.S. Preventive Services Task Force can wield the authority granted to them by the ACA, and whether the religious freedom of the plaintiffs was violated.</p>
<p>O’Connor <a href="https://www.healthaffairs.org/content/forefront/court-holds-key-aca-preventive-services-requirements-unconstitutional">agreed</a> that allowing the U.S. Preventive Services Task Force this authority violated the <a href="https://www.law.cornell.edu/constitution/articleii">appointments clause</a> of the Constitution, which specifies that people using government powers must be “officers of the United States.” In this case, O'Connor ruled that U.S. Preventive Services Task Force members do qualify as officers, but their appointment is unconstitutional because they are not appointed by the President and confirmed by the Senate.</p>
<p>This paves the way for the repeal of Section 2713 and allowing insurers to decide what, if any, preventive care would remain free to patients in their plans. He also argued that because the ACA “force[s] Braidwood to [cover] services to which it holds sincere religious objections … offering coverage is itself a tacit endorsement of the behaviors that [the plaintiff] believes the services encourage.”</p>
<h2>Losing access to preventive care</h2>
<p>PrEP is a major component of the prevention pillar of the United States’ “<a href="https://www.cdc.gov/endhiv/about.html">Ending the HIV Epidemic</a>” initiative and has <a href="https://www.aidsmap.com/news/sep-2019/prep-reducing-hiv-diagnoses-us-cities-independently-effect-treatment">successfully reduced HIV diagnosis rates</a> in areas where it is highly used. If this ruling were to extend nationally, over <a href="https://dx.doi.org/10.1016%2Fj.annepidem.2018.06.009">170,000 current PrEP users</a> and <a href="https://doi.org/10.1016/j.annepidem.2018.05.003">over 1 million people</a> who can benefit from this medicine could be affected.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Red ribbon hanging from the North Portico of the White House" src="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434528/original/file-20211129-19-1jm1jvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">PrEP is a key tool to helping the U.S. reach its goal of substantially reducing new HIV infections by 2030.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/ObamaWorldAidsDay/c146dee7e944420482f3e5786d4d2e50">AP Photo/Pablo Martinez Monsivais</a></span>
</figcaption>
</figure>
<p>Removing the cost barrier to PrEP made it more accessible with commercial insurance, the primary source of health coverage for <a href="https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202108-508.pdf">over two-thirds of the population</a> under age 65. Raising the cost barrier again would <a href="https://doi.org/10.1001/jamanetworkopen.2021.22692">disproportionately harm</a> younger patients, people of color and those with lower incomes. Black men who have sex with men could be particularly affected because of the structural barriers they face, despite having <a href="https://doi.org/10.1016/S0140-6736(12)60899-X">no more “risky” sexual behavior</a> on average than other men who have sex with men.</p>
<h2>What’s next?</h2>
<p>For now, the religious freedom portion of the ruling is specific to PrEP and Braidwood Management’s purchase of plans that cover PrEP. It is unclear whether the order will apply only to these plaintiffs or nationwide. </p>
<p>The next filings, where both sides will begin to provide more information on how they believe the ruling should be applied, are due by <a href="https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.94.0_1.pdf">Sept. 16, 2022</a>. As of yet, there is no timeline for a concrete decision.</p>
<p>For the time being, access to PrEP, contraception, cancer screenings and all other forms of preventive care made free by the ACA continue to be available. Regardless of O’Connor’s final decision, this case seems likely to be appealed to the Supreme Court, where another showdown over the fate of a substantial part of the ACA will be decided.</p>
<p><em>Portions of this article originally appeared in previous articles published on <a href="https://theconversation.com/the-next-attack-on-the-affordable-care-act-may-cost-you-free-preventive-health-care-166087">Sep. 7, 2021</a> and <a href="https://theconversation.com/hiv-prevention-pill-prep-is-now-free-under-most-insurance-plans-but-the-latest-challenge-to-the-affordable-care-act-puts-this-benefit-at-risk-171086">Dec. 1, 2021</a>.</em></p><img src="https://counter.theconversation.com/content/190317/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Shafer has received funding in the past three years from the Commonwealth Fund, Arnold Ventures, Robert Wood Johnson Foundation, Kate B. Reynolds Charitable Trust, Starbucks Coffee Company, and Renova Health.</span></em></p><p class="fine-print"><em><span>Kristefer Stojanovski has received funding in the past from the Robert Wood Johnson Foundation, the National Institute of Minority Health & Health Disparities, the National Institute of Mental Health, and the Fulbright Program</span></em></p>Judge Reed O'Connor ruled in a case that coverage for HIV prevention medicine PrEP violated the religious freedom of the plaintiffs. It is unclear whether the order will extend nationwide.Paul Shafer, Assistant Professor of Health Law, Policy and Management, Boston UniversityKristefer Stojanovski, Research Assistant Professor of Social, Behavioral and Population Sciences, Tulane UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1662302021-09-22T12:58:23Z2021-09-22T12:58:23ZSpreading HIV, the virus that causes AIDS, is against the law in 37 states – with penalties ranging up to life in prison<figure><img src="https://images.theconversation.com/files/417668/original/file-20210824-19578-1mmip0.jpg?ixlib=rb-1.1.0&rect=56%2C0%2C6240%2C4082&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical experts have recommended that HIV criminal laws be revised.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/prisoner-at-the-bolivar-county-correctional-facility-waits-news-photo/1315034536">Spencer Platt / Staff / via Getty Images News</a></span></figcaption></figure><p>Despite the fact that HIV is now a treatable medical condition, the majority of U.S. states still have laws on the books that criminalize exposing other people to HIV. Whether or not the virus is transmitted does not matter. Neither does a person’s intention to cause harm. A person simply must be aware of being HIV-positive to be found guilty. </p>
<p>These laws are <a href="https://doi.org/10.1007/s10461-013-0408-1">enforced mainly on marginalized people living in poverty</a> who cannot afford lawyers. The penalties – <a href="https://www.hivlawandpolicy.org/news/chlp-releases-date-analysis-us-laws-criminalize-disease-2020">felony convictions and being placed on sex offender registries</a> – are severe and life altering. </p>
<p>It is difficult to know exactly how many people are affected by HIV criminal laws, since a central <a href="https://doi.org/10.1007/s10461-016-1540-5">database of such arrests does not exist</a>. The HIV Justice Network has collected a <a href="https://www.hivjustice.net/country/us/?">partial list of 2,923 HIV criminal cases</a> since 2008 based on media reports. </p>
<p>I am a <a href="https://scholar.google.com/citations?hl=en&user=pR7k3XQAAAAJ">professor of social work</a> who studies the impact of HIV criminal laws <a href="https://doi.org/10.1080/15381501.2021.1963385">from the perspective of people who have been arrested</a>. My research shows such statutes are outdated, harm people living with HIV and exacerbate the spread of the virus by driving people into hiding and away from treatment services. </p>
<h2>The early years of AIDS</h2>
<p>In 1981, the U.S. Centers for Disease Control and Prevention reported <a href="https://pubmed.ncbi.nlm.nih.gov/6789108/">the first cases</a> of what later would be called acquired immune deficiency syndrome, or AIDS. By 1982, researchers had strong evidence the disease could be transmitted through blood and sexual activity. At the time, the <a href="https://doi.org/10.1126/science.7089584">death rate for AIDS patients was estimated to be 65%</a>. </p>
<p>In 1983, scientists discovered the <a href="https://doi.org/10.1126/science.6189183">retrovirus that causes AIDS</a> and named it the human immunodeficiency virus, or HIV. Initially, HIV infection was reported mainly in gay men, but as time went on, <a href="https://ari.ucsf.edu/about-us/history-aids-ucsf">it was diagnosed in other populations, including women and children</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Three people at cubicle desks under a banner reading 'National AIDS Hotline - Information, Education, Referrals.'" src="https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Operators at the National AIDS Hotline run by the American Social Health Association in 1991.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AIDSEPIDEMIC1991/9c157ac90ce8da11af9f0014c2589dfb/">AP Photo/Karen Tam</a></span>
</figcaption>
</figure>
<p>In 1994, <a href="https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline">AIDS was the leading cause of death</a> for all Americans ages 25 to 44. Medical treatment for the disease was in its infancy. Both factors fueled the public’s fear of being exposed to AIDS. A diagnosis seemed like a death sentence.</p>
<h2>Criminal laws</h2>
<p>The 1988, Ronald Reagan’s <a href="https://doi.org/10.1111/j.1746-1561.1988.tb00559.x">Presidential Commission on the HIV Epidemic</a> recommended that states establish criminal penalties as a way of deterring people with HIV from engaging in behavior likely to transmit the virus. The <a href="https://www.govtrack.us/congress/bills/101/s2240/text">1990 Ryan White CARE Act</a>, which provided major funding for HIV services, required states to certify they had adequate laws in place to prosecute individuals who knowingly exposed another person to HIV.</p>
<p>In 1990, 14 states had HIV criminal laws. By 2005, <a href="https://doi.org/10.1007/s10461-006-9117-3">23 states had them</a> – even though the <a href="https://bibleandbookcenter.com/read/ryan-white-care-act-reauthorization/">reauthorization of the Ryan White CARE Act in 2000</a> removed the criminalization requirement. Today, these laws are <a href="https://www.cdc.gov/hiv/policies/law/states/exposure.html">on the books in 37 states</a>.</p>
<h2>Unintended consequences</h2>
<p>From the outset, experts across many disciplines <a href="https://www.ucpress.edu/book/9780520291607/punishing-disease">voiced concern about the effectiveness of using punitive criminal laws</a> as a way of deterring the spread of HIV.</p>
<p>Indeed, HIV criminal laws have backfired from a public health perspective. A 2017 study found people living in states with HIV criminal laws are <a href="https://doi.org/10.1097/QAD.0000000000001636">less likely to get tested and know their HIV status</a> than those in states without HIV laws. Stigma and fear of prosecution discourage people from seeking information or help.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People in a parade carrying a banner that reads 'HIV Stigma Stops Here.'" src="https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Minnesota AIDS Project banner at the Twin Cities Pride Parade in Minneapolis in 2013.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/87296837@N00/9180874836">Tony Webster/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>This lack of knowledge is significant because pharmaceutical treatments, beginning in 1996 with highly active antiretroviral therapy, or HAART, have steadily <a href="https://www.niaid.nih.gov/diseases-conditions/hiv-treatment">transformed HIV into a chronic manageable condition</a>.</p>
<p>Medical experts have <a href="https://doi.org/10.1007/s10461-016-1540-5">recommended that HIV criminal laws be revised</a>. However, <a href="https://scholarship.law.cornell.edu/clr/vol94/iss3/13">most state legislatures have not done so</a>. </p>
<p><a href="https://www.hivjustice.net/global-hiv-criminalisation-database/cases/">These laws are regularly enforced</a> – most often on members of stigmatized groups, including those who are <a href="https://doi.org/10.1007/s10461-013-0408-1">homeless or suffering from an addiction or mental illness</a>. Research has also documented that HIV criminal laws are <a href="https://www.thebody.com/article/hiv-criminalization-and-people-of-color">disproportionately applied to people of color</a>. In fact, the majority of people arrested for an HIV crime <a href="https://doi.org/10.1007/s10461-013-0408-1">are members of multiple minority communities</a>. </p>
<p>Being arrested for an HIV-related crime is often devastating for individuals – beginning with the permanent exposure of personal health information to the public. For indigent defendants, felony charges pursued by a county’s district attorney will result in the appointment of a <a href="https://vanderbiltlawreview.org/lawreview/2020/05/plea-bargaining-and-collateral-consequences-an-experimental-analysis/">public defender, who will most likely counsel a guilty plea</a> – regardless of whether the individuals believe they are guilty or even understand the consequences of such a plea. </p>
<p>Sentences for violating HIV exposure statutes are comparable to sentences for vehicular homicide and <a href="https://www.cdc.gov/hiv/policies/law/states/exposure.html">can be as severe as life in prison</a>. A 2017 analysis of 393 convictions in Arkansas, Florida, Louisiana, Michigan, Missouri and Tennessee found the <a href="https://www.ucpress.edu/book/9780520291607/punishing-disease">average sentence for an HIV-related crime was 92 months</a> – or nearly eight years in prison. </p>
<p>Incarceration can result in <a href="https://www.brennancenter.org/sites/default/files/2020-09/EconomicImpactReport_pdf.pdf">permanent restrictions on employment, housing, education and voting</a>. </p>
<p>Additionally, six states currently <a href="https://www.hivlawandpolicy.org/resources/chart-state-state-criminal-laws-used-prosecute-people-hiv-center-hiv-law-and-policy-2012">place people convicted of an HIV-related crime on the sex offender registry</a>, which results in lifetime sex offender status – a relentless and unending punishment. </p>
<h2>Treatment lowers risk</h2>
<p>The HIV epidemic in the U.S. has changed tremendously in the past 40 years. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Three people hold signs saying 'Free HIV testing now' and 'Ask about Prep/Pep now.'" src="https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Volunteers hold signs promoting free HIV testing and information during the Harlem Pride parade in New York City on June 29, 2019.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/volunteers-hold-signs-as-they-promote-free-hiv-testing-news-photo/1152819576">KENA BETANCUR / Contributor / AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>HIV exposure laws have not kept up with the changes in HIV science and treatment. People with knowledge of their HIV status can <a href="https://www.cdc.gov/hiv/risk/art/index.html">receive treatment that makes them unable to transmit the virus</a>. Proven prevention methods such as <a href="https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/HIV-Proven-Prevention-Methods-508.pdf">HIV testing, treatment and preexposure prophylaxis, or PrEP</a>, are tools that remove the justification for HIV criminal laws.</p>
<p>Scientists can identify solutions to public health challenges, but it takes action by <a href="https://www.annualreviews.org/doi/pdf/10.1146/annurev.publhealth.25.101802.123126">politicians to turn solutions into policy</a>. HIV criminal laws are largely ignored because the people they directly affect are not connected to political power. </p>
<p>Bipartisan support is needed to replace existing laws with proven public health interventions.</p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p><img src="https://counter.theconversation.com/content/166230/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Lennon-Dearing has recieved funding from the University of Memphis Foundation and currently receives funding from the National Institutes of Health under Grant 2P30AI042853-21. She is a member and consultant for the Tennessee HIV Modernization Coalition.</span></em></p>Current HIV criminal laws increase HIV stigma and discrimination against marginalized people – and negatively affect public health.Robin Lennon-Dearing, Associate Professor of Social Work, University of MemphisLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/882552017-12-01T12:33:07Z2017-12-01T12:33:07ZOne year in: lessons on rolling out an HIV prevention pill in South Africa<figure><img src="https://images.theconversation.com/files/197282/original/file-20171201-10147-184x2y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">NIAID</span></span></figcaption></figure><p>Last year South Africa became the first country on the continent to register the use of a drug that could be used as an oral pre-exposure prophylaxis for HIV prevention. Pre-exposure prophylaxis, referred to as PrEP, is the use of anti-retroviral drugs by people who do not have HIV to prevent them from becoming infected. </p>
<p>The idea behind PrEP has been to target high risk populations where new infections remain consistently high. This includes sex workers, men who have sex with men, injection drug users and young women.</p>
<p>Following a <a href="http://apps.who.int/iris/bitstream/10665/197906/1/WHO_HIV_2015.48_eng.pdf">recommendation</a> by the World Health Organisation to use the drug as an additional HIV prevention choice South Africa registered <a href="http://www.mccza.com/documents/2e4b3a5310.11_Media_release_ARV_FDC_PrEP_Nov15_v1.pdf">Tenofovir/Emtricitabine</a> last year.</p>
<p>By June this year South Africa’s PrEP programme was being implemented at 17 sites that were serving sex workers and men who have sex with men. The programme had also been expanded to provide the drug at nine clinics at seven tertiary institutions which serve more than 120,000 young people. </p>
<p>The PrEP rollout data shows that there is a relatively slow, but increasing, uptake of PrEP. There are concerns. One year after the licence was procured there are fears that the rollout isn’t sufficiently targeting one of the country’s most high risk populations: young women.</p>
<p>This is a critical cohort of people in the fight against new HIV infections. Studies show that young women in South Africa, aged between 15 and 24 years have the <a href="http://www.unaids.org/en/resources/campaigns/2014/2014gapreport/gapreport">highest HIV incidence</a>. About 1,745 new HIV infections occur among these young women every week. </p>
<p>An additional factor that makes the group so important in bringing down infections is that they represent a <a href="http://www.indexmundi.com/south_africa/demographics_profile.html">substantial section</a> – about 10% – of the population. </p>
<p>Unless this problem is solved the rates of new infections in South Africa are unlikely to be reduced. </p>
<h2>Great idea, challenging to deliver</h2>
<p>After South Africa procured the licence for the HIV prevention tablet, the National Department of Health launched a national policy and set of guidelines to rollout PrEP and provide test and treat services. Test and treat allows people to access antiretrovirals as soon as they test positive.</p>
<p>The government’s cost-effectiveness analyses suggested that the greatest impact of PrEP would be in populations that have a substantial risk for HIV infection. As a result the policy focused initially on providing PrEP at a limited number of sex worker sites. This would help them learn more about real world delivery prior to scale up. </p>
<p>But here lies the issue. There is a high level of political will and desire in the government to rollout PrEP to young women who are at risk, but the health system requirements are complex. Cost is also a consideration. There is a need to establish how best to identify young women at highest risk and how best to offer and retain young women on PrEP. </p>
<h2>Next steps</h2>
<p>PrEP is new technology that has the potential to alter the HIV epidemic particularly among women. But a narrow focus on a single technology alone is unlikely to solve health and social challenges associated with HIV. </p>
<p>South Africa needs to pay careful attention to access and service delivery issues and constraints, and to engage communities as PrEP is scaled up so that its potential is fully realised.</p>
<p>There are a number of small scale research projects mainly in and around Johannesburg and Cape Town that could help inform how best to deliver PrEP to young women. More than 500 adolescent girls and young women between the ages of 16-24 years are being enrolled in the projects. The aim is to to learn more about scalable models of PrEP delivery for adolescents in countries like South Africa which has limited resources. </p>
<p>Without an understanding of best practices and most cost effective scalable delivery models for young women, it will be challenging for South Africa to maximise the impact of core HIV prevention, treatment, and care interventions. </p>
<p>Another critical step to filling the gaps would be to generate greater community awareness about PrEP. Many people don’t know that there is an antiretroviral pill that, if taken every day, can reduce a person’s risk of being infected with HIV. Getting the message across is difficult because the legacy of concerns about antiretrovirals and their side effects persist in many communities. </p>
<p>This is not just about awareness but about the need for a broader conversation about how we address the underlying issues that continue to shape HIV risks in young women. Stigma, violence against women, judgemental attitudes about young people having sex all make it more difficult for people to accept PrEP and to use it effectively. </p>
<p>A broader conversation is needed to increase knowledge and awareness of PrEP, its potential to change the course of the epidemic, and where it fits in to a broader programme of HIV prevention.</p><img src="https://counter.theconversation.com/content/88255/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sinead Delany-Moretlwe has received a drug donation from Gilead Sciences for a demonstration project.</span></em></p><p class="fine-print"><em><span>Saiqa Mullick does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>South Africa’s data rollout of its pre-exposure prophylaxis shows that there is a relatively slow, but increasing, uptake. However, more needs to be done to target young women.Sinead Delany-Moretlwe, Associate Professor and Director: Research at the Wits Reproductive Health and HIV Institute I, University of the WitwatersrandSaiqa Mullick, Director of Implementation Science, Wits Reproductive Health & HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/875492017-11-22T12:17:48Z2017-11-22T12:17:48ZThree decades on, stigma still stymies HIV prevention and treatment<figure><img src="https://images.theconversation.com/files/195175/original/file-20171117-7545-1xb416z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There have been great strides and many important victories in the fight against HIV. <a href="https://theconversation.com/rings-and-things-other-ways-to-prevent-hiv-are-on-the-cards-69192">Scientific innovations</a> and <a href="https://www.gatesfoundation.org/Media-Center/Press-Releases/2002/11/HIVAIDS-Prevention-Effort-in-India">sustained investment</a> have been the most important weapons in this ongoing battle.</p>
<p>Nevertheless the epidemic retains a powerful grip – especially on people in Africa. In sub-Saharan Africa, 19.4 million are living with the virus. In 2016 an estimated 15 000 new infections occurred every week in the region.</p>
<p>Treatment and prevention of HIV are twin endeavours; they rely universally on two elements. The first is the interaction of HIV positive and negative people with HIV services. The second is the willingness of people to modify their risky behaviour and avoid negative health consequences.</p>
<p>Adherence is the cornerstone of these processes: a commitment to taking medication or adopting a risk-reducing behaviour consistently over time. By adhering to their antiretroviral (ARV) regimens those living with the virus are able to lead long, healthy lives. They are able to eliminate the chance of passing on the virus to their partner(s). The concept of an <a href="https://www.preventionaccess.org">undetectable virus is an untransmissable</a> one is now acceptable. </p>
<p>With good adherence to an HIV prevention pill or pre-exposure prophylaxis (PrEP) or consistent use of condoms, HIV negative people can protect themselves from infection.</p>
<p>But real and perceived stigma can undermine all these efforts. This is because stigma stops people from getting tested, stops them discussing their test results with intimate partners when they do test, and then staying on their treatment. Unless stigma is addressed, the aim of ending the AIDs epidemic by 2030 – one of the United Nations’ Sustainable Development Goals – is unlikely to become a reality.</p>
<h2>The logic behind stigma</h2>
<p>Stigma happens when disgrace and shame become associated with an attribute, such as being HIV positive. It results in the person with the attribute being discredited or socially renounced. When stigmatised beliefs are widely held in a community, hostility and discrimination towards stigmatised people becomes common.</p>
<p>A stigmatised person can start to believe these views as well and develop a self-depreciating internal representation of themselves. This is known as internalised stigma. It can lead to diminished mental health and emotional distress. Both general and internalised HIV-related stigma can compromise a person’s ability to seek and stay on treatment. And it can prevent people from taking steps to prevent infection.</p>
<p>For instance, a woman living with HIV could choose not to go back for more medication because she’s scared someone from her community will see her and learn her status.</p>
<p>Conversely, a sexually active teenager might not ask a healthcare professional how she can prevent HIV if she is afraid of being judged for having sex.</p>
<p>There is evidence that these scenarios still play out. The HIV Stigma Index conducted in South Africa in 2014 found that about 45% of the respondents experienced internalised stigma. And 39% lived in fear of potential stigma. Young people between the ages of 15 and 24 were particularly affected by all types of stigma.</p>
<h2>Stigma on top of stigma</h2>
<p>Stigma has the negative psychological consequence of making it more difficult for people to cope and find social support. It also reduces their ability to overcome other barriers to adherence, such as unfriendly healthcare services or side effects from medication.</p>
<p>The research shows that people who do not experience internalised stigma tend to be more successful in adhering to treatment and more capable of overcoming other barriers to access treatment and prevention services.
HIV stigma poses additional difficulties for positive people who already belong to stigmatised population groups, such as men who have sex with men transgender people, sex workers, and people who inject drugs.</p>
<p>Stigma against these groups already reduces access to healthcare services and social support. But disclosure of being HIV positive can result in people facing even more stigma, discrimination and hostility.</p>
<p>This is especially the case in African countries where homosexuality and sex work are criminalised.</p>
<p>Moralistic support for criminalisation often interferes with public health initiatives. As a result, stigmatised populations are frequently made more vulnerable to HIV infection due to this discrimination and restricted access to healthcare services.</p>
<h2>Changing the tide</h2>
<p>The good news is that stigma can be reduced if three basic interventions are put in place.</p>
<p>Firstly, through the implementation of effective and sustained mass media campaigns and health promotion aimed at dispelling the common myths. These campaigns should involve HIV positive people as message bearers.</p>
<p>Secondly, normalising and promoting the interaction with HIV prevention services. What is needed here are more people openly engaging about HIV testing and taking PrEP (pre-exposure prophylaxis).</p>
<p>And thirdly laws and policies that protect those living with the virus from discrimination and promote them being able to access healthcare services.
These are especially important for key population groups living in countries where criminalisation disrupts public health strategies.</p><img src="https://counter.theconversation.com/content/87549/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker receives funding from a number of academic funding agencies including the NIH (USA). She is currently the President of the International AIDS Society.</span></em></p>Stigma stops people from getting tested for HIV, and staying on their treatment. Unless it’s addressed, the AIDS epidemic will persist.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/804832017-09-12T15:18:09Z2017-09-12T15:18:09ZKenya embraces new prevention efforts to reduce HIV infection<figure><img src="https://images.theconversation.com/files/183433/original/file-20170825-1020-50p6nu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Antiretroviral drugs suppress the HIV virus and stop progression of the disease.</span> <span class="attribution"><span class="source">Reuters/Finbarr O'Reilly</span></span></figcaption></figure><p>Kenya’s health authorities <a href="http://www.nation.co.ke/news/Govt-launches-two-approaches-to-fight-HIV-Aids/1056-3914614-8p6ubc/index.html">launched</a> a new way to reduce the spread of HIV among its people.</p>
<p>It is the <a href="https://www.chskenya.org/media_centre/national-launch-prep-hiv-self-testing-guidelines/">second African country</a> after <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2016/november/20161104_PrEP-ZA">South Africa</a> to have <a href="http://www.nation.co.ke/news/Govt-launches-two-approaches-to-fight-HIV-Aids/1056-3914614-8p6ubc/index.html">pre-exposure prophylaxis guidelines </a>. </p>
<p>This <a href="http://www.whatisprep.org/">pre-exposure prophylaxis</a> (PrEP) joins other prevention and treatment methods already in use in Kenya. It involves giving antiretroviral (ARV) drugs to people who are not infected with HIV but are at high risk of infection. Taking the drug reduces the chances of HIV infection.</p>
<p>Over the last thirty years, <a href="http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdf">77 million people worldwide</a> have been infected with HIV and 39 million (51%) of them have died from AIDS related illnesses.</p>
<p>During the first 20 years of the epidemic, up to the mid 2000s, antiretroviral treatment was not widely available. In 2006, for example, <a href="http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdf">less than 10%</a> of HIV positive people globally were on ARV therapy.</p>
<p>In the 1990s, the ARV drugs were largely <a href="http://www.thebody.com/content/art2646.html">experimental</a> and extremely expensive. In addition, patients had to take several different drugs at least twice a day. Because it was complicated, some patients either took the drugs inconsistently or stopped altogether. </p>
<p>Most of the world’s HIV infected people were in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445041/">low-income countries</a>. The question was how to finance such a potentially expensive programme of treatment.</p>
<p>The early to mid 2000s brought a <a href="http://www.who.int/3by5/publications/documents/en/Treating3millionby2005.pdf">rapid increase</a> in ARV treatment availability, spurred by human rights groups who made a strong case for <a href="https://cdn1.sph.harvard.edu/wp-content/uploads/sites/480/2013/01/Reich_Bery_AIDS_drugs.pdf">expanded access</a>. </p>
<p>By 2010, more than <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445041/">6.6 million HIV positive</a> people globally were getting treatment. By 2016, <a href="http://nacc.or.ke/wp-content/uploads/2016/11/Kenya-AIDS-Progress-Report_web.pdf">66% of HIV-infected adults</a> in Kenya were on ARVs.</p>
<h2>Test and treat campaign</h2>
<p>It is estimated that there are <a href="https://unitaid.eu/news-blog/kenya-introduce-better-treatment-people-living-hiv">1.5 million HIV positive</a> people in Kenya now and the <a href="http://nacc.or.ke/wp-content/uploads/2016/11/Kenya-AIDS-Progress-Report_web.pdf">prevalence</a> has declined from about 10% in 2000 to 5.9% in 2016. </p>
<p>In the past, treatment was delayed until a person became very sick. Today, HIV positive people begin antiretroviral treatment <a href="http://apps.who.int/iris/bitstream/10665/251713/1/WHO-HIV-2016.24-eng.pdf">as soon as they are diagnosed</a>. This not only prolongs life but reduces the risk of new infections. </p>
<p>When a patient takes the medication properly, ARVs prevent the virus from multiplying. HIV positive people then become almost non-infectious and could, in theory, have unprotected sex with HIV negative people with little risk of infecting them with the virus.</p>
<p>Now, by making ARVs available to HIV negative people in the high risk group, Kenya is expected to <a href="https://www.standardmedia.co.ke/article/2001232533/government-to-roll-out-anti-retroviral-drug-to-hiv-negative-people">significantly reduce</a> their chances of getting HIV. </p>
<p>If the preventive treatment is taken as per instructions, it could reduce the risk of HIV <a href="https://www.cdc.gov/hiv/basics/prep.html">by almost 90%</a>. This means that if one hundred people who would otherwise get infected take the medication every day as recommended, 90 of them will likely not get infected. In reality, however, most people do not take medication as required all the time and most studies have shown an overall reduction <a href="https://www.cdc.gov/hiv/risk/prep/index.html">risk by about 75%.</a></p>
<h2>Patterns of HIV infection in Kenya</h2>
<p>Progress in the fight against HIV has been accompanied by a major shift in the <a href="http://nacc.or.ke/wp-content/uploads/2016/11/Kenya-AIDS-Progress-Report_web.pdf">patterns of infection</a> in Kenya. </p>
<p>Female sex workers, men who have sex with men, people who inject drugs and adolescent girls continue to be disproportionately affected by HIV. They account for almost <a href="http://nacc.or.ke/wp-content/uploads/2016/11/Kenya-AIDS-Progress-Report_web.pdf">90% of new infections</a> in Kenya. This is because unlike in the rest of the population where new HIV infections have gone down to a large extent, new infections have remained fairly constant among these groups. </p>
<p>In 2015, almost half of the new HIV infections in Kenya were among girls and young women aged 15 to 24 years. Their <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4344544/">vulnerability to HIV infection</a> is due to limited knowledge on HIV/AIDS. Young girls are also unable to negotiate for safe sex due to poverty and peer pressure. Female sex workers and men who have sex with men account for <a href="http://nacc.or.ke/wp-content/uploads/2016/11/Kenya-AIDS-Progress-Report_web.pdf">about a third</a> of new HIV infections. </p>
<h2>New prevention tool</h2>
<p>In Kenya, the focus of PrEP is on female sex workers, men who have sex with men, HIV negative people in relationships with HIV positive people, and adolescent girls and young women in areas with high numbers of new infections.</p>
<p>The treatment is given as a daily tablet containing either one drug (tenofovir) or a <a href="https://www.ncbi.nlm.nih.gov/pubmed/28208119">combination of two drugs</a> (tenofovir and emticitrabine).</p>
<p>Both are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2387297/">common ARV drugs</a> often used as part of the treatment for HIV positive patients. In addition to oral PrEP, there are other forms of HIV prevention such as vaginal rings and gels, but they are not as widely available as the tablets, anywhere in the world.</p>
<p>Research is continuing into other forms of PrEP such as a <a href="https://www.sciencedaily.com/releases/2017/07/170724090832.htm">monthly injection</a> to make it easier for people to follow the treatment.</p>
<h2>Efficacy and safety profile</h2>
<p>This medicine does not work well if the person doesn’t closely follow the instructions for its use.</p>
<p>It is useful for HIV prevention, but does not protect against other sexually transmitted infections or unintended pregnancies.</p>
<p>It is very safe to use, though. It can have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4244494">side effects</a> like mild abdominal discomfort, nausea and vomiting, but they clear up within two weeks of starting the treatment.</p>
<p>There is only a small risk of kidney and liver damage for people who already have kidney disease due to high blood pressure, infections or diabetes. PrEP is also <a href="http://jamanetwork.com/journals/jama/fullarticle/1889140">safe in pregnancy</a> and does not interfere with most family planning methods.</p>
<h2>The future</h2>
<p>Governments need to start and continue <a href="http://www.nation.co.ke/news/Govt-launches-two-approaches-to-fight-HIV-Aids/1056-3914614-8p6ubc/index.html">public health campaigns</a> to increase awareness of this HIV prevention method. This will help high risk groups to protect themselves from infection.</p>
<p>Campaigns should make sure that women know about PrEP, because it may be easier for them to take tablets than to get a man to use a condom. </p>
<p>Until there is a vaccine or a cure for HIV, success depends on using all the available ways of preventing infection.</p><img src="https://counter.theconversation.com/content/80483/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Griffins Manguro does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The introduction of Pre Exposure Prophylaxis drugs in Kenya aims at reducing new HIV infections among people facing substantial ongoing risk.Griffins Manguro, PhD candidate, Ghent UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/694992016-12-06T14:30:27Z2016-12-06T14:30:27ZWhat can be done to turn the tide of HIV among young girls in sub-Saharan Africa<figure><img src="https://images.theconversation.com/files/148596/original/image-20161205-19399-1hbqxjo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A young woman performs at an HIV prevention campaign during the International Aids Conference 2016.</span> <span class="attribution"><span class="source">International AIDS Society/Abhi Indrarajan</span></span></figcaption></figure><p>There’s a lot of good news about HIV/AIDS. Worldwide there has been a <a href="http://www.unaids.org/en/resources/campaigns/get-on-the-fast-track">steady decline</a> in the number of people between the ages of 15 and 24 being infected with HIV. The decline has been linked to behaviour changes such as waiting longer to become sexually active, having fewer multiple sex partners and using condoms in multiple partnerships. </p>
<p>In South Africa, however, this is not the case. The drop in the number of adolescent girls and young women becoming HIV positive is too slow and too little. In 2012 11.4% of young women aged 15 to 24 were HIV positive compared to <a href="http://www.hsrc.ac.za/uploads/pageContent/4565/SABSSM%20IV%20LEO%20final.pdf">2.9% of young men</a>. Four years earlier, this figure sat at 13.9% for young women compared to <a href="https://www.health-e.org.za/wp-content/uploads/2013/05/2966e129fc39e07486250fd47fcc266e.pdf">3.6% of young men</a>. </p>
<p>And when you put this in the context of the global picture it is equally as startling: <a href="http://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/overview">42% of new HIV infections</a> occur in people aged between 12 and 24. Nearly 80% of these young people live in sub-Saharan Africa. And more than 70% of these infections occur in adolescent girls and young women.</p>
<p>Not only do these adolescent girls and young women have higher rates of HIV, they also acquire infection between five and seven years earlier than their male peers. </p>
<p>The quest to stem these infections is an important part of reducing the high rates of HIV among adolescent girls and young women in sub-Saharan Africa. Knowing your HIV status is an important part of this. But in South Africa this knowledge remains very low. Less than 50% of young people know their status. South Africa is worse off than many other countries. </p>
<p>So how can the country ensure that more adolescent girls are able to test for HIV and, where necessary, start taking antiretrovirals?</p>
<p>The answer lies in implementing extensive combination prevention programmes in high-prevalence settings for both men and women. This needs to include early antiretroviral treatment, provision of pre-exposure prophylaxis and medical male circumcision. There also needs to be a concerted effort to promote knowledge of HIV status, comprehensive age appropriate education in schools, economic empowerment and easy access to sexual and reproductive health services. </p>
<h2>Why are women so vulnerable</h2>
<p>The persistently high gender imbalance of HIV among young people has led to an increase in research to understand the disparate burden and associated risks facing adolescent girls and young women. </p>
<p>A number of contributory factors have been identified. </p>
<p>Part of the disconnect among women about their HIV status and their vulnerability relates to their perceptions that they have a low risk to HIV. This in turn perpetuates vulnerability to HIV, particularly in situations of high household poverty levels and unemployment.</p>
<p>Living in a society where patriarchy is embedded and gender inequality is rife also plays a major role. In these settings young women and girls are often limited from reaching their full potential because they do not finish school. Studies have shown that premature school leavers are more disadvantaged and that women who finish school have better job opportunities and the ability to make better life decisions.</p>
<p>Much attention has been paid to the role that age-disparate heterosexual relationships may play in this gender imbalance. <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0159162">Several studies</a> show when there are larger age differences among sex partners, there is a higher chance of condoms not being used. This in turn leads to higher rates of sexually transmitted infections among adolescent girls and young women. </p>
<h2>Cycle of HIV transmission</h2>
<p>A <a href="http://link.springer.com/article/10.1007%2Fs11904-016-0314-z">recent study</a> involving women living in areas where HIV prevalence is as high as 66% among women in their 30s shows that the greatest difference in HIV prevalence is among men and women in the younger age groups. This reinforces the notion that women on average acquire HIV at a younger age than men.</p>
<p>The study helped explain a continuous “cycle of HIV transmission” between older men and younger women. But this transmission heightens the vulnerability of adolescent girls and young women to HIV. </p>
<p>This is because most younger women (aged 15 to 25) had male partners on average up to nine years older than them. Adolescent girls and young women in these age-disparate relationships are generally unable to negotiate safer sex practices involving the use of condoms, increasing the chance of them contracting HIV.</p>
<p>These women who acquire HIV, over time once they reach the age of 25, also have relationships with men of their own age who in turn acquire HIV. These men then have new relationships with younger women aged 15 to 25, spreading the virus and contributing to the cycle of HIV transmission. </p>
<h2>Programmes that work</h2>
<p>South Africa has made substantial progress in the large scale roll-out of HIV prevention and treatment programmes and has the <a href="https://africacheck.org/reports/yes-south-africa-has-the-worlds-largest-antiretroviral-therapy-programme/">largest antiretroviral programme</a> in the world. But young women are uniquely vulnerable to infection, and preventing HIV acquisition in this key population is a public health imperative.</p>
<p>Understanding the cycle of transmission and the sexual networks that drive HIV transmission could help design programmes to reduce HIV infection in adolescent girls and young women.</p>
<p>There are many <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2015/november/20151117_dreams">programmes</a> which could help adolescent girls and young women making an informed decision. These programmes also increase and retain their attendance in schools, reduce teenage pregnancies and gender-based violence and increase economic opportunities for young people. Most importantly they interrupt the cycle of transmission and decrease new HIV infections. </p>
<p>While these programmes exist, in many instances they are not delivered in the most appropriate way that ensures they influence young women’s thinking.</p><img src="https://counter.theconversation.com/content/69499/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ayesha BM Kharsany does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Stemming high HIV rates among adolescent girls and young women in sub-Saharan Africa has become a challenge due to the cycle of transmission.Ayesha BM Kharsany, Senior Scientist at CAPRISA, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/691922016-11-27T10:13:13Z2016-11-27T10:13:13ZRings and things … other ways to prevent HIV are on the cards<figure><img src="https://images.theconversation.com/files/147636/original/image-20161126-32008-25tr76.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pre-exposure prophylaxis is providing an exciting new innovation to tackle HIV prevention. </span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>The rate of HIV infection remains greater than the number of people initiating treatment. This imbalance will stop the eradication of HIV/AIDS. It begs for increased investment into primary prevention.</p>
<p>Primary prevention caters to people who are HIV negative. It aims to reduce their chance of becoming infected. There are certain populations, now referred to as <a href="http://apps.who.int/iris/bitstream/10665/197906/1/WHO_HIV_2015.48_eng.pdf">key populations</a>, in whom the burden of infection is disproportionately high. These include men who have sex with men, sex workers, people who inject drugs, transgender people, and, in sub-Saharan Africa, adolescent girls and young women. Primary prevention should be tailored, and scaled up, for these groups.</p>
<p>Primary prevention can be provided in a number of ways. But the most exciting new innovation is pre-exposure prophylaxis (PrEP). PrEP is the use of anti-retrovirals by HIV-uninfected people to prevent HIV transmission. It is commonly given as a daily pill (sold as <a href="https://theconversation.com/how-a-drug-can-help-prevent-5000-girls-being-infected-with-hiv-every-week-52539">Truvada</a>) to be taken orally in the same way that contraceptives are used to prevent pregnancy or antimalarial pills are taken before travelling to a high malaria risk area.</p>
<p>Numerous <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1011205">clinical trials</a> and demonstration projects in diverse settings and populations have been conducted with PrEP all showing that it works. PrEP is easy to take. It is also largely side effect free and safe. There is one hitch: it has to be taken consistently at the time of HIV exposure. Adherence has been oral PrEP’s biggest stumbling block. </p>
<p>That’s why a huge effort is being made to find alternative ways to take PrEP. New formulations in the pipeline include long-acting injections, monthly vaginal rings, implants and topical gels, films and dissolving topical pills. The hope is that new formulations will make PrEP more accessible and convenient, particularly for adolescents and young people who may find a daily intervention cumbersome.</p>
<h2>Adherence is PrEP’s Achilles’ heel</h2>
<p>Adherence is key. To block HIV transmission PrEP must be “in the system” at the time of HIV exposure. Its effectiveness decreases rapidly when this “effective coverage” is inconsistent. Good adherence gives almost 100% HIV transmission prevention. Poor adherence results in little to no protection. </p>
<p>This is why, where possible, a daily dose during times of risk is recommended. But this may be difficult to achieve for some.</p>
<p>In PrEP trials the following reasons were given for poor adherence:</p>
<ul>
<li><p>fear/experience of side effects, </p></li>
<li><p>fear of interactions with alcohol and other drugs, </p></li>
<li><p>forgetfulness, </p></li>
<li><p>dislike of pill-taking, and </p></li>
<li><p>fear of the discrimination associated with taking an anti-HIV pill. </p></li>
</ul>
<p>Alternative dosing strategies using longer acting formulations and PrEP delivery methods may well be another way to increase PrEP effectiveness.</p>
<h2>New PrEP frontiers</h2>
<p>Topical gels, which can be applied pre and post sex to rectal and vaginal tissue, were the first alternative formulations to be tested. But the results in women have been inconsistent. This formulation still holds promise in men who have sex with men although efficacy trials haven’t yet been conducted.</p>
<p>An alternative strategy is a monthly vaginal ring, which in its current form contains slow-release dapivirine (another antiretroviral). <a href="https://theconversation.com/why-a-new-vaginal-ring-could-be-a-game-changer-in-hiv-prevention-55367">Two large phase III clinical trials</a> have demonstrated that the ring is effective and can reduce the chance of HIV infection by 27%-31%. In a sub analysis of different ages, older women once again fared better than young women. </p>
<p>The benefit of the vaginal ring is that there are less side effects because the drug is released locally and only a small amount enters the blood stream. The other huge plus is that women are encouraged to insert and forget, only changing the ring on a monthly basis. The obvious catch is that this is only suitable for women and vaginal intercourse. </p>
<p>The vaginal ring is undergoing further investigation.</p>
<p>Another tool that is being investigated and could overcome the need for a daily pill is a long-acting monthly injection. An injection of the antiretroviral cabotegravir (cabotegravir LA) has been shown to be very effective at lowering viral loads in people being treated for HIV when administered every two months. </p>
<p>Also being investigated are dissolving vaginal films – a bit like the breath fresheners that can be bought over the counter – as well as quick dissolving pills. </p>
<p>Perhaps most exciting of all is the prospect of an implant, a small rod which can be surgically placed just under the skin and will be able to slowly release antiviral protection over months. </p>
<p>Finally, new formulations are currently being investigated that will combine treatment for both contraception and preventing sexually transmitted infections. It is hoped that these multifunctional preventions may further encourage people to consistently use these products.</p>
<p>A new challenge to the field is how these new clinical trials can be efficiently designed. To qualify for first-line use of PrEP, new pills and products will need to have improved or equivalent efficacy compared to the current oral PrEP. And they would need to have reduced or equivalent side effects. All these formulations and delivery methods are still in the early stages of testing, but look to be out on the market within the next two to five years depending on their success.</p>
<h2>PrEP for Africa</h2>
<p>In sub-Saharan Africa, teenage girls and young women are <a href="http://www.unaids.org/en/resources/documents/2014/Adolescentgirlsandyoungwomen">most at risk of HIV</a> infection. There are 2000 new infections in this group every week. These women are vulnerable because of the high prevalence of both gender-based violence and the commonality of age-disparate relationships and transactional sex. These conditions can make it difficult for women to negotiate safer sex practices. PrEP would enable these women to protect themselves in advance, without their partner’s knowledge or consent.</p>
<p>Kenya and <a href="http://www.mccza.com/documents/2e4b3a5310.11_Media_release_ARV_FDC_PrEP_Nov15_v1.pdf">South Africa</a> are the only two African countries that have granted regulatory approval for PrEP. Neither have started to roll it out. </p>
<p>New interventions can only be useful if deployed and scaled up to the populations most in need. This raises questions of cost versus impact. It is hoped that new formulations and delivery systems will enhance choice, encourage use, and provide a platform from which PrEP roll out can be advocated.</p><img src="https://counter.theconversation.com/content/69192/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker receives funding from a variety of research funding agencies. She is affiliated with The Desmond Tutu HIV Centre at University of Cape Town. She is conducting an adolescent PrEP demonstration study in which Gilead has donated oral Truvada. </span></em></p>Trials have shown that rates of HIV infection are reduced if people not infected with HIV take anti-retrovirals - known as pre-exposure prophylaxis (PrEP). But adherence to a daily dose is a problem.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/628662016-07-22T09:49:50Z2016-07-22T09:49:50ZAIDS conference 2016: the gains, the gaps, the next global steps<figure><img src="https://images.theconversation.com/files/131486/original/image-20160721-32639-1es3x1p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Young women who attended the International AIDS Conference in Durban, South Africa.</span> <span class="attribution"><span class="source">International AIDS Society/Rogan Ward</span></span></figcaption></figure><p><em>As the 21st International AIDS Conference wraps up in Durban, South Africa, Professor Linda-Gail Bekker, incoming International AIDS Society President, talks to The Conversation Africa health and medicine editor Candice Bailey about what was achieved and what still needs to be done.</em></p>
<p><strong>What are the three interventions or innovations that stand out at the conference in terms of taking the fight against HIV forward?</strong></p>
<p>There has been exciting work about how we do treatment better to make sure we get to the 34 million who are infected. And that’s absolutely critical. We have to reach those 34 million people but we know that health systems, particularly in the sub-Saharan region, are struggling. So there was some wonderful work on differentiated models of care, how we can do business more effectively and efficiently and ways we can do the steps in the cascade more efficiently. </p>
<p>And I’ve loved some of the testing innovations. Addressing all the steps from testing is critical. </p>
<p>Secondly I’m passionate about primary prevention but I think we’ve got some gaps on how we can do it. I’m a great proponent of daily pre-exposure prophylaxis and I really think we should roll it out because it works. But I’m very excited about the prospect of what’s coming down the road in terms of less frequent dosing for pre-exposure prophylaxis.</p>
<p>Number three is a fresh approach to adolescents. This conference has reinvigorated the notion that we have to get adolescents to the table. We have done well, I think, in getting adolescents to be really well represented. And it works. You feel their voice. </p>
<p>The message I have heard here is that we need to have an integrated approach. We can’t just talk HIV treatment or just HIV prevention. It has to take into consideration structural issues, behavioural issues, rights, access – a lot of issues. And I think it becomes a model of how we really look after our adolescents around the world and HIV is a great catalyst within that. </p>
<p><strong>Based on the discussions at the conference where are the gaps in the global HIV response?</strong></p>
<p>At the moment it’s money. There is a horrible funding gap that we have to address. We had so much money when we didn’t have the tools. Now we have the tools and we don’t have the money. I feel desperate about that.</p>
<p>In 2000 we missed opportunities because we didn’t have our systems and our thinking right. I’m taking collective responsibility but there was a leadership gap and we lost lives because of that. Here we stand now and if we don’t act in the way that we should, we will have lots of lost lives and infections that we don’t have to. And I don’t want that on my record. </p>
<p>When we get help from Sir Elton John, Prince Harry, Princess Mabel from The Netherlands and Charlize Theron to shine a focus on this we are eternally grateful. We need help from everyone to carry the message that the job isn’t done. Otherwise we will miss the moment and we will have regrets. And I don’t want to be in that camp. </p>
<p>I am very pleased that the <a href="http://www.theglobalfund.org/en/replenishment/">Replenishment of the Global Fund Conference</a> is being held in Canada because I think the Prime Minister of Canada is really showing that he can get the job done. Justin Trudeau’s a great example of moving forward when he needs to move forward and doing uncomfortable things when they have to be done because it’s right. I have a sense that he does what’s right. So I’m excited about that because I think that’s important. </p>
<p>We have to keep showing people that it’s not only the right thing and the compassionate thing and the humane thing but that it makes good financial sense. We are bleeding where we don’t need to bleed in terms of finance. And if we can shut it down earlier we will do the world a favour. </p>
<p><strong>What is the message that is coming out of this conference?</strong></p>
<p>The job is not done. We have tools that can be deployed; we have a lot of work to do. We have the energy but this is not the time to not have the resources. It’s a collective global effort. And we’re excited. </p>
<p>Durban has re-energised the whole sense of community and engagement. Now we need the rest of the world to get on board. And I think we can do it. The optimism that I have felt here is real. But the reality is that if we don’t move forward from today that trajectory will flatten out.</p>
<p><strong>As incoming International AIDS Society president what would you like your legacy to be?</strong></p>
<p>I think the tagline of the conference is the legacy: access and equity and making sure no-one is left behind. The best bang we can get for our buck is that we don’t make HIV languish because in the long term it will cost more. If we want to see a good response we have to be speedy about it. </p>
<p>Traditionally this conference has not always been the place where new science is shown. But it was brought to our attention beautifully that there is hope in vaccines and there is hope in treatment remission and so the ongoing innovation is still critical. We can talk about minimising disease and reducing statistics but if we really want to talk about eradication, we are going to have to find ourselves a vaccine that works. That is the ultimate investment. </p>
<p>I’m so excited that my country is playing such a significant role in that solution. I’m really proud to be South African. We have 54 million people in a very big world of people but we are playing a significant role. We have made lemonade out of lemons. </p>
<p>We have the biggest burden. In some ways we were the pariah in 2000 – we were failing on so many levels. But we have changed that and we are contributing, we are not only surviving and that is an extraordinary privileged position to be in. And I’m hoping young people in South Africa will get that and will get on board. It’s a mission and we are all looking for a mission. We fought for our freedom and now we are fighting for our futures and that’s significant.</p><img src="https://counter.theconversation.com/content/62866/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The focus of the 2016 International AIDS Conference has on access to necessary antiretrovirals, equity and making sure no-one is left behind. But there is a funding gap that needs to be addressed.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/623602016-07-21T17:34:05Z2016-07-21T17:34:05ZIt’s not enough to test for HIV and treat it – social factors matter too<figure><img src="https://images.theconversation.com/files/131403/original/image-20160721-32610-4vnigg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Testing and treatment is important in tackling HIV. But stigma and access need to be addressed too.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Giving HIV-positive people access to antiretrovirals as soon as they become infected is an important step in controlling the infection. The challenge lies in making sure people who know they are infected actually take the drugs.</p>
<p>Taking antiretrovirals results in viral suppression by lowering the amount of virus in the bodily fluid of those infected with HIV. This makes them less infectious to other people. It is key to reducing HIV infection rates.</p>
<p>The World Health Organisation’s <a href="http://www.who.int/hiv/pub/guidelines/en/">new recommendation</a> is that a person who tests HIV positive should start treatment immediately. But in South Africa, at the moment, only patients with a CD4 count of 500 receive antiretrovirals. This policy is due to change in September 2016, when all those diagnosed with HIV will be eligible for treatment. As a result it is hoped that many more people will move onto treatment, towards the estimated <a href="http://www.unaids.org/en/regionscountries/countries/southafrica">six million people</a> in the country living with HIV.</p>
<p>We undertook a <a href="http://www.avac.org/trial/anrs-12249-tasp">clinical trial</a> in KwaZulu-Natal province to find out whether the rate of new infections in a certain geographical area where everyone was tested and treated with antiretrovirals would be lower than in those areas where only people with CD4 counts of 500 were treated.</p>
<p>The trial was one of four treatment-as-prevention studies around the world. The KwaZulu-Natal study is the first to report its findings. The others are in Botswana, Kenya, Uganda and Zambia.</p>
<p>It was hypothesised that the KwaZulu-Natal study would demonstrate a 34% drop in new infections.</p>
<p>But our study found that there was no difference in the rate of new infections between people who have access to antiretrovirals from the get-go, and those who only have access at a certain stage of immunological decline. </p>
<p>Instead, we found that only 50% of the people who were tested and found to be positive visited a clinic within a year of being diagnosed HIV positive. And this tells us that even when people have access to treatment, the challenge lies in making sure they collect the medicine as soon as they are aware of their status. </p>
<p>While the biological approach is important, it is insufficient on its own. Our study highlighted many social and infrastructural barriers to getting people onto treatment. A series of social and behavioural factors needs to be considered in the context of preventing HIV. </p>
<p>The findings are important because they come months before South Africa begins implementing the new treatment policy. </p>
<h2>How we did it</h2>
<p>The trial took place in an area around the Africa Centre for Population Health. The centre is based in the Mtubatuba, a town in northern KwaZulu-Natal. The area around the centre has one of the highest prevalence of HIV in the world: about 30%.</p>
<p>We identified 22 geographical clusters of 1,000 people per cluster. Everyone in that population of the cluster was recruited and tested for HIV in their homes. </p>
<p>The clusters then fell into one of two groups. Depending on the cluster, people were either offered treatment according to the South African National Department of Health’s current national guidelines. This is based on their immune status. Or they received treatment for HIV regardless of immune status. </p>
<p>The care and mobile clinics were located near people’s homes. </p>
<p>But there were two significant factors at play. First, even after people were tested in their homes, found to be infected and provided with local clinics to access treatment, we found it difficult to get them to attend the clinics. Only 50% of those who tested positive got to clinics within a year of being diagnosed HIV positive. As a result they didn’t benefit from early treatment and reduction of infection. </p>
<p>Second, a large number – even up to about 50% – described that their most recent sexual partner was outside the study area. </p>
<h2>Reduction in viral loads</h2>
<p>The trial participants who were tested and who got into care and were treated showed significant reduction in their viral loads. This means that they could be considered non-infectious.</p>
<p>The big challenge we encountered was that the number of people who got into care was lower than we wanted. This may be the explanation for the fact that the rate of new HIV infections was not affected in ways we had anticipated.</p>
<p>A number of factors contributed to this. One of our findings is that it was more difficult to test men for HIV and, second, it was more difficult for those men to get into care. When they got into care, they did just as well as women. </p>
<p>There remains a significant stigma around HIV in this population. Not wanting to be seen in a clinic may have been a contributing factor.</p>
<h2>What’s missing</h2>
<p>With the national guidelines in South Africa changing, the trial highlights how to best treat everyone to maximise the effect. It shows that unless this policy is associated with increased effort to provide care and treatment and encourage people to come for treatment, then the benefit of treating everyone won’t materialise.</p>
<p>What this means is that we need to look at whether treatment can be given in people’s homes – or if there are other things that will encourage people to come to clinics, such as mobile phone technology that reminds them to do so. Even incentives to come to clinics may be an option. </p>
<p>Those clinics also need to be more friendly and efficient. They must be run in a way that ensures that waiting periods are minimal so that people aren’t required to take time off from work. And the stigma issue needs to be addressed to ensure that people aren’t uncomfortable and worried about coming to the clinic. </p>
<h2>Positive lessons</h2>
<p>There were also positive things that came out of the trial. These included:</p>
<ul>
<li><p>research teams having no challenges accessing the homes and households of all 22,000 people in the 22 clusters. This means the approach to gathering information at this level is feasible; </p></li>
<li><p>people accepting our approach; and </p></li>
<li><p>participants being happy that clinics were near their homes so they did not have to spend a large amount of money on transport to get to clinics. Transport costs were previously identified as a barrier in access to care.</p></li>
</ul>
<p>The research has provided valuable insights into what needs to be done to reduce the HIV infection rate in South Africa, which remains the highest in the world. This, as the country prepares for one of the biggest changes in policy since antiretrovirals were first introduced.</p><img src="https://counter.theconversation.com/content/62360/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The treatment as prevention trial (ANRS 12249) was funded by the French ANRS and the Bill and Melinda Gates Foundation through 3ie. </span></em></p>Taking antiretrovirals is key to reducing HIV infection rates, but the challenge lies in making sure people who know they are infected actually take the drugs.Deenan Pillay, Director of the Africa Centre for Population Health and Professor of Virology, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/624792016-07-18T12:29:13Z2016-07-18T12:29:13ZHow three new studies unravel South Africa’s patterns of HIV transmission<figure><img src="https://images.theconversation.com/files/130885/original/image-20160718-2110-ob5v2v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The more scientists understand about what drives HIV transmission, the more they can start to fight the virus.</span> <span class="attribution"><span class="source">Rupak De Chowdhuri/Reuters</span></span></figcaption></figure><p><em>Young women bear a disproportionate burden of HIV in sub-Saharan Africa – and South Africa has a particular challenge. In some parts of the country more than 36% of people are HIV positive.</em> </p>
<p><em>Three studies conducted by the Centre for the AIDS Programme of Research in South Africa (Caprisa) in rural and urban sub-districts of the KwaZulu-Natal province provide new insights into the engine that drives HIV transmission in the country. They also reveal a new way to tackle the problem of HIV. Caprisa’s director Professor Salim Abdool-Karim explains the latest findings.</em> </p>
<p><strong>What did you discover about the patterns of HIV transmission?</strong></p>
<p>Our first study focused on interrogating the age-disparate sexual relationships between older men and younger women. This would help us better understand who was infecting young girls within the community. </p>
<p>The study used gene sequencing on HIV positive people within the community to get a clearer picture of how many people had the same or similar versions of the virus. It was found that in about a third of the sample, they could link people to a cluster where there was the same or similar virus to others in that community.</p>
<p>This data showed that adolescent girls and young women were contracting HIV from their partners, who were on average eight years older. These older men were simultaneously in sexual relationships with women – of similar ages to the men – who have HIV prevalence rates exceeding 60%. While the fact that young women are engaged in sexual relationships with older men is not new information, this study provides insight into how HIV is transmitted within this community.</p>
<p>This is where the “cycle of transmission” became apparent. Older women, who are HIV positive, are in relationships with men the same age as themselves. However these men, who are mostly unaware of their HIV status, are then also sleeping with younger women. The younger women will then contract HIV and when they grow up they will become the source of infection for men in the same age group as them. This perpetuates the cycle.</p>
<p><strong>What additional factors account for the high infection rates in adolescent girls?</strong></p>
<p>In addition to this “cycle of transmission”, our other two studies revealed biological factors that put young women at high risk of HIV infection. We did this by analysing vaginal bacteria. The second study looked at the genetic codes of vaginal bacteria of 119 South African women. </p>
<p>It was found that women who had an abundance of a naturally present bacterium (Prevotella bivia) had a 13-fold increased risk of acquiring HIV. Overgrowth of the bacteria resulted in a protein called lipopolysaccaride being released which increased genital inflammation 20-fold. This genital inflammation increases vulnerability to HIV infection and places young women with excess Prevotella bivia at greater risk of becoming HIV positive.</p>
<p>The third study also looked at genital bacteria in women. Here we wanted to gain a better understanding of the efficacy of tenofovir gel being used as a pre-exposure prophylaxis (PrEP). </p>
<p>It showed that tenofovir gel was effective in three out of five women who had a dominant presence of a bacteria called lactobacillus. Lactobacillus bacteria is naturally present in the vagina and helps maintain an acidic pH. This is beneficial as it maintains a “healthy” vaginal environment.</p>
<p>Women with low levels of this bacteria had increased levels of Gardnerella vaginalis – a bad bacteria naturally which is naturally present in the vagina. This poses a problem to the efficacy of tenofovir, since Gardnerella absorbs the tenofovir drug. This reduces the amount of tenofovir present and inhibits the efficacy of PrEP.</p>
<p>The results of these studies and the new information they provide enable us to re-examine HIV prevention interventions to break the cycle of transmission. The presence of Prevotella and Gardnerella can both easily be tested for. There is a readily available antibiotic treatment should women require it. </p>
<p>These new targeted interventions can have a significant impact on reducing the spread HIV and reducing the risk young women face of becoming HIV positive in South Africa.</p>
<p><strong>How do you break this transmission?</strong></p>
<p>Our studies show that there are a complex set of social and behavioural factors that have an impact on HIV transmission. Treatment is key but you need additional measures. Circumcision in young men will reduce their risk of contracting HIV but there may still be some transmission. Young girls also need to be protected with pre-exposure prophylaxis. </p>
<p>In total, test and treat initiatives with circumcision and PrEPs are a combination that can break the patterns of HIV transmission. But the critical issue is that we cannot adopt an ostrich approach to older men sleeping with younger women. We need a new set of community norms. </p>
<p>These studies can also be applied to Eastern Africa and the rest of southern Africa, where 70% of the HIV population lives, to see if there are similar results. This would inform policies to tackle the problem of HIV transmission.</p><img src="https://counter.theconversation.com/content/62479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>These studies were funded by PEPFAR, Centers for Disease Control and Prevention, the M·A·C AIDS Fund, USAID and the Canadian Institutes for Health research. </span></em></p>Three new studies conducted in South Africa provide insights into the engine that drives HIV transmission in the country.Salim Abdool Karim, Director , Centre for the AIDS Program of Research in South Africa (CAPRISA)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/553672016-03-01T04:28:29Z2016-03-01T04:28:29ZWhy a new vaginal ring could be a game-changer in HIV prevention<figure><img src="https://images.theconversation.com/files/113373/original/image-20160301-8057-vbe88q.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">supplied</span></span></figcaption></figure><p>The results of the two studies showing that a vaginal ring can help reduce the risk HIV infection among women is being hailed as an important HIV prevention <a href="http://www.nytimes.com/2016/02/23/health/vaginal-ring-hiv-aids-drug-dapivirine.html?_r=0">breakthrough</a>. </p>
<p>Launched four years ago, the two clinical trials, known as <a href="http://www.mtnstopshiv.org/news/studies/mtn020/factsheet">ASPIRE</a> and <a href="http://www.ipmglobal.org/the-ring-study">The Ring Study</a>, set out to determine how safe and effective the ring was in prevention of HIV infection in women. The ring, which is used for a month at a time, contains an antiretroviral drug called dapivirine that acts by blocking HIV from multiplying. </p>
<p>The studies enrolled close to 4500 women aged 18 to 45 in South Africa, Uganda, Malawi and Zimbabwe. Each study found that the ring helps reduce the risk of HIV infection in women. In ASPIRE, the ring reduced the risk of HIV infection by 27% overall. In The Ring Study, infections were reduced by 31% overall.</p>
<p>But there were differences in how effective the ring was based on how consistently the women used it. Both studies showed that the more consistently the ring is used, the more effective it is in protecting women. </p>
<p>For women aged 18 to 21 in both studies there was no significant protection because they did not use the ring consistently. ASPIRE found that HIV protection was greater in groups with evidence of better ring use. Incidence of HIV was cut by more than half – 56% – among women 21 and older, who, as a group, appeared also to use the ring most consistently. </p>
<p>The studies show that the ring has the potential to help make a difference in reducing the burden of HIV by at least one third in women overall. This has significant implications for reducing the burden of disease in women in Africa.</p>
<h2>Women can have another option</h2>
<p>It is the first time two phase-three clinical trials have confirmed statistically significant efficacy for a <a href="http://www.who.int/hiv/topics/microbicides/microbicides/en/">microbicide</a> to prevent HIV. The dapivirine ring was designed to offer potentially long-acting protection against HIV through slow, continuous delivery of dapivirine into the vaginal tissues over the course of four weeks. </p>
<p>Women account for nearly 60% of <a href="http://www.unaids.org/en/resources/campaigns/2014/2014gapreport/gapreport">adults with HIV</a>. Unprotected heterosexual sex drives this figure. Despite tremendous advances in preventing and treating HIV, women still face a disproportionate risk of infection because there are insufficient practical HIV prevention options available to them.</p>
<p>If the ring becomes available for commercial use it will add to the tools in the HIV prevention toolbox for women alongside female condoms and Truvada, an antiretroviral tablet taken by HIV negative people as daily pre-exposure prophylaxis.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=418&fit=crop&dpr=1 600w, https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=418&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=418&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=525&fit=crop&dpr=1 754w, https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=525&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/113187/original/image-20160229-4063-11nlun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=525&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Truvada is a pre-exposure antiretroviral tablet.</span>
<span class="attribution"><span class="source">EPA/Maurizio Gambarini</span></span>
</figcaption>
</figure>
<p>In 2015, South Africa and Kenya joined the US in <a href="https://theconversation.com/how-a-drug-can-help-prevent-5000-girls-being-infected-with-hiv-every-week-52539">approving Truvada</a>. Pre-exposure prophylaxis has been proven to be very effective for people at risk of HIV. </p>
<p><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1011205">Studies</a> have shown that Truvada provides users with up to 90% protection provided it is taken consistently. In earlier studies it was shown to be less successful in women who did not take the drug daily. </p>
<h2>Hurdles that need to be cleared</h2>
<p>There are still several more steps that need to be followed before the ring becomes available to women. </p>
<p>Dapivirine was originally developed as an oral antiretroviral compound. This was tested in phase- one and two <a href="http://www.ipmglobal.org/our-work/ipm-product-pipeline/dapivirine-tmc120">clinical trials</a> with more than 200 participants. </p>
<p>Although it was first conceived as an oral therapeutic, dapivirine became a promising topical microbicide candidate because it was effective both in vitro and in vivo, had a favourable safety profile, and the right physical and chemical properties.</p>
<p>To licence the product, the ring must be approved for public use by global and national regulatory authorities. Because at least two phase three efficacy trials are needed for regulators to approve a licence for the product, the two phase-three trials were conducted in parallel to speed up the process to potentially approve the ring. </p>
<p>Licensure is an important but complex and timeous process. The authorities will review the comprehensive dossier of scientific evidence when deciding to licence the ring. The ring’s developer, <a href="http://www.ipmglobal.org/about-ipm/how-we-work">International Partnership for Microbicides</a>, a global health non-profit enterprise, will follow this process.</p>
<h2>Next round of studies</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/113188/original/image-20160229-4080-5rcaha.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The dapirivine vaginal ring.</span>
<span class="attribution"><span class="source">Supplied</span></span>
</figcaption>
</figure>
<p>In the meanwhile, as the ring is under regulatory review, there are several more studies planned. Two of the studies are open-label extension (OLE) studies called DREAM and HOPE. </p>
<p>These OLE studies aim to provide all women who participated in the phase-three trials access to the dapivirine ring. This will help understand how the ring is used in a real world setting now that the level of effectiveness is known and also inform its future roll out. These studies are currently being reviewed by local regulators. </p>
<p>A third study, MTN-034, that is also under review, will offer women both the dapivirine ring and oral Truvada. Targeted at adolescent girls and young women between the ages of 16 and 21, this study will help understand what young women want and how they respond to the active products once they know their levels of effectiveness. </p>
<p>This study is important because across both efficacy trials, women aged 18 to 21 showed no significant protection because they did not use the ring consistently. Young women <a href="http://www.unaids.org/en/resources/documents/2014/Adolescentgirlsandyoungwomen">aged 15 to 24</a> are at the highest risk of HIV infection globally and so this is clearly an age group where research is needed. </p>
<p>But poor adherence may not be the only reason for the lack of protection among these women. Further research is needed to understand if there are biological or physiological factors that may affect how dapivirine is taken up in vaginal tissue, or whether the trial design itself is especially intimidating to young women. </p>
<p>Not knowing whether they are using an active product or a placebo, or how safe and effective it is, may have influenced their use.</p><img src="https://counter.theconversation.com/content/55367/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thesla Palanee-Phillips receives funding from the National Institutes of Health, DFID and USAID</span></em></p>If the vaginal ring becomes available for commercial use it will become one of the tools in the HIV prevention toolbox for women alongside female condoms and daily pre-exposure prophylaxis.Thesla Palanee-Phillips, Director: Clinical Trials, Wits Reproductive Health and HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/548582016-02-18T03:59:30Z2016-02-18T03:59:30ZThe scientific journey of AIDS from despair to cautious hope<figure><img src="https://images.theconversation.com/files/111801/original/image-20160217-19250-830qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Treatment has transformed the outlook for people living with HIV from almost certain death to a manageable chronic condition.</span> <span class="attribution"><span class="source">Athit Perawongmetha/Reuters</span></span></figcaption></figure><p>From our current perspective, it is easy to forget that at the beginning of the AIDS pandemic, scientists did not even know the identity of the infectious agent causing a rare immunodeficiency. Rapid scientific advancement was needed to implement even basic public health measures such as laboratory-based testing to identify infected individuals and screen the blood supply. </p>
<p>In 1984, three years after the first AIDS reports, the human immunodeficiency virus was identified, followed the next year by the first licensed test. Following from these early advances, research has revealed the HIV disease process, developed major new therapies, and designed methods of prevention.</p>
<h2>From treatment to combination prevention</h2>
<p>Research has enabled scientists to discover two crucial things: key targets for antiretroviral therapies and then highly effective multi-drug regimens. Treatment has transformed the outlook for people living with HIV from almost certain death to a manageable chronic condition. </p>
<p>Critically, the treatment revolution led not only to vast improvement in human lives but also to crucial vehicles for prevention and public health. Beyond the success of preventing perinatal transmission, the two key public health breakthroughs are treatment as prevention, and pre-exposure prophylaxis.</p>
<p>The extraordinary success of research has brought a shift toward “combination prevention”. This is defined as rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions to have a sustained impact on reducing new infections. </p>
<p>Evidence-based prevention tools include pre-exposure prophylaxis, preventing perinatal transmission, universal treatment and voluntary male circumcision. These happen with testing, counselling, condoms, harm reduction, and education.</p>
<p>These developments have shifted the discourse over AIDS exceptionalism. The issue now is not so much that public health and civil liberties are in tension but rather that AIDS has captured a disproportionate amount of political attention and economic resources. </p>
<p>The very success of the AIDS movement has sparked a debate about the ethical allocation of scarce resources.</p>
<h2>Game changing interventions</h2>
<p>Although there is much to celebrate in the incredible scientific advances of the last three decades, key breakthroughs remain elusive. There is broad scientific consensus that “getting to zero” requires an effective vaccine. </p>
<p>Results from a 2009 trial in Thailand showed a 31% vaccine efficacy in preventing HIV infections. Although the vaccine conferred only modest protection, the results were the “proof of concept”, instilling new hope for a game-changing intervention.</p>
<p>Recent work at Oregon Health and Science University reignited hope of an AIDS vaccine. In this study 16 rhesus monkeys infected with simian immunodeficiency virus were given an experimental vaccine. Nine were protected from the virus’ effects and apparently “cleared” of infection.</p>
<p>The 2012 International AIDS Conference also saw renewed optimism toward a cure, with the report of the “Berlin patient”. The patient was cured of the infection after a bone marrow transplant from a donor carrying the genetic variant, which provided resistance to HIV. There are two cases where people who underwent bone marrow transplants appeared to be virus-free once their antiretrovirals were stopped.</p>
<p>While bone marrow transplants will never be practical for large numbers of people, genetically based HIV treatment could emerge. In 2013, researchers announced that an HIV infected infant treated aggressively with antiretrovirals 30 hours after birth had no detectable viral levels at one month of age. </p>
<p>If confirmed, this case could transform treatment for newborns, providing hope for the estimated 330,000 HIV-infected infants in the developing world. Finding a cure would close a critical innovation gap, removing the need for arduous lifelong treatment regimes.</p>
<p>Another potentially game-changing innovation would be a female controlled prevention method, such as an effective vaginal microbicide gel. Clinical trials show it could be effective in reducing the risk of contracting HIV during sex. The option of taking preventive measures without their partner’s agreement or knowledge would give women greater autonomy over their sexual health.</p>
<p>At the same time, scientists will be pressed to overcome the problems associated with current treatment regimes. These include drug resistance, chronic adverse effects and the need for more easily administered and cost-effective formulations. These breakthroughs require continued investment in research while addressing many pressing needs not only for HIV/AIDS, but in global health more broadly.</p>
<h2>Allocating scarce resources</h2>
<p>Even with considerable global funding devoted to HIV/AIDS (US$7.86 billion in foreign assistance in 2012), resources remain scarce. It requires agonising decisions on how to allocate life-saving interventions. </p>
<p>Who should receive treatment when all cannot access it? Should priority go to research, prevention, or treatment? And, ultimately, should AIDS receive a higher priority than other health threats? These are life-and-death questions for millions of people, and there is no consensus on the right answers.</p>
<p>Although resources have risen, drug scarcity is a fact of life, and will be for the foreseeable future. Without a major decrease in HIV incidence, competition for treatment resources will only become more intense. </p>
<p>While the global community cannot even meet current treatment needs, there will be additional calls for treatment expansion – for example, expanding PrEP. The future portends ever-increasing strains on existing drug resources in a time of scale austerity.</p>
<p>In a resource-constrained world, allocation decisions rest on multiple factors: </p>
<ul>
<li><p>the level of immune dysfunction that triggers treatment initiation; </p></li>
<li><p>treatment costs (first- or second-line); and</p></li>
<li><p>the use of anti-retroviral therapy for prevention or treatment. </p></li>
</ul>
<p>In allocating resources, which population groups, countries and regions deserve priority? Those with the greatest number of HIV-infected people, those with the lowest treatment coverage, or those where the most people can be reached at the lowest cost? </p>
<p>These are excruciating choices, as they often determine who will live when everyone cannot.</p>
<hr>
<p><em>This is the second of <a href="https://theconversation.com/africa/topics/aids-global-health-series">three articles</a> drawn from the book <a href="http://www.hup.harvard.edu/catalog.php?isbn=9780674728844.">Global Health Law</a>, released by Professor Lawrence Gostin.</em></p><img src="https://counter.theconversation.com/content/54858/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lawrence O. Gostin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Despite the breakthroughs in HIV and AIDS research, without an effective vaccine, the world will not get to zero new infections and deaths.Lawrence O. Gostin, Professor of Global Health and Director, O'Neill Institute, Georgetown UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/543932016-02-17T04:29:07Z2016-02-17T04:29:07ZAIDS: how far the world has come and how far it needs to go to get to zero<figure><img src="https://images.theconversation.com/files/111626/original/image-20160216-19232-18o0se6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man lights candles as part of a World AIDS Day event in Jakarta.</span> <span class="attribution"><span class="source">Dadang/Tri</span></span></figcaption></figure><p><em>Foundation essay: Our foundation essays are longer than usual and take a wider look at key issues affecting society.</em></p>
<p>There is no story in global health as transformative, awe-inspiring, and yet as tragic as the AIDS pandemic. The disease was unknown only a generation ago — a medical curiosity among young gay men in New York and San Francisco in June 1981. </p>
<p>Within a few short years, AIDS could be found on every continent, enveloping the world to become one of the most devastating pandemics in human history. It has caused untold human suffering, social disintegration, and economic destruction.</p>
<p>In the early days of the pandemic, public health officials relied on prevention strategies devised for other sexually transmitted diseases. This includes testing, counselling, education, condoms and partner notification. </p>
<p>Newly diagnosed people had an average survival period of six to eight months. And their weakened immune systems made them vulnerable to rare cancers, pneumonias, chronic fatigue and horrific wasting until death ensued. </p>
<h2>The early years of fear, pain and despair</h2>
<p>The socio-political response was, at best, denial, ignorance, and silence. Ronald Reagan, US President at the time, did not utter the word “AIDS” in public until 1986. At worst, it was social marginalisation, discrimination, and punishment. People were blamed for their own suffering and criminalised for their behaviour. The fear, pain, and despair faced by people living with AIDS and their loved ones cannot be overstated.</p>
<p>But by 2010, <a href="http://www.unaids.org/">UNAIDS</a> announced a goal that was once unimaginable: <a href="http://www.unaids.org/sites/default/files/sub_landing/files/JC2034_UNAIDS_Strategy_en.pdf">getting to zero</a>. Zero new infections, zero AIDS-related deaths and zero discrimination. </p>
<p>The 2012 International AIDS Conference was held in the US for the first time in 22 years because the US restricted entry of persons living with HIV between 1990 and 2011. At the conference, then Secretary of State Hillary Clinton called for an AIDS-free generation. To be sure, these high hopes provoked a skeptical response, with experts saying the goal was unrealistic and open-ended. What exactly is the definition of “zero” or “AIDS-free,” and which generation are we talking about? </p>
<p>But stepping back from perennial debates about aspiration tempered by realism, it is impossible not to marvel at the technological advances that enabled global health leaders to say the unthinkable: that we may one day see the end of the scourge of AIDS.</p>
<h2>Powerful technological interventions</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=913&fit=crop&dpr=1 600w, https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=913&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=913&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1147&fit=crop&dpr=1 754w, https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1147&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/111627/original/image-20160216-19232-nxqh9n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1147&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
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</figure>
<p>The technological advances that made all this possible include, first and foremost, <a href="http://www.who.int/hiv/topics/treatment/en/">antiretroviral</a> treatments. A newly diagnosed 25-year-old today can expect to live another 50 years on treatment. But it also includes combination prevention, which extends well beyond traditional methods of testing, counselling, condoms and education. These do remain vital. </p>
<p>Research has shown remarkable reductions in HIV transmission from <a href="http://www.who.int/hiv/topics/malecircumcision/en/">male circumcision</a>, pre-exposure <a href="https://www.aids.gov/hiv-aids-basics/prevention/reduce-your-risk/pre-exposure-prophylaxis/">prophylaxis</a> (PrEP), and antiretroviral therapy. </p>
<p>At the 2011 International AIDS Conference, scientists announced a jaw-dropping 95% plus reduction in sexual transmission among heterosexual couples adhering to antiretroviral treatment.</p>
<p>What if it were possible to reach every person at risk, or already infected, with these powerful interventions? What if the next discovery could empower women to protect themselves, such as with a vaginal <a href="http://www.who.int/hiv/topics/microbicides/microbicides/en/">microbicide</a>, which is on the horizon? Given the political will, isn’t it imaginable that the international community could “get to zero”?</p>
<p>How did all these technological advances come about, and why did this particular disease forge a pathway toward unprecedented scientific discoveries? Very sadly, science has not been able to match these technological advances for most global health challenges. Not mental illness, cancer, or tuberculosis. </p>
<p>It has been said that these are all highly complex, multi-factorial diseases, while AIDS is not. But this is far from the truth.</p>
<h2>Social mobilisation like never before</h2>
<p>AIDS is one of the most complicated and stubbornly persistent diseases the world has ever known. Yet the sociopolitical dimension of AIDS has galvanised perhaps the greatest social mobilisation around a health crisis that the world has seen. </p>
<p>From the AIDS Coalition to Unleash Power <a href="http://www.actupny.org/documents/capsule-home.html">(ACT UP)</a> and Lambda Legal <a href="http://www.lambdalegal.org/">Defense</a> in the US to the Treatment Action <a href="http://www.tac.org.za/">Campaign</a> in South Africa, courageous individuals and organisations have literally transformed the politics of AIDS, turning neglect and derision into empowerment and social action.</p>
<p>This vast social mobilisation was targeted not only at fighting the social dimensions of this disease with poignant calls for dignity, nondiscrimination, and justice. It was perhaps principally about access to medicines. </p>
<p>AIDS campaigns had crisp clarity, appealing to a basic sense of social justice: the rich have access to life sustaining medicines while the poor do not. This message resonated in developed countries where the poor often were denied access to antiretroviral medication. But it also resonated in developing countries where most people could not afford a life-saving pill that the majority of those in the developed world could access.</p>
<p>The access-to-medicines campaigns brought AIDS advocates to pursue solutions beyond the health sector. Activists directly attacked the prevailing trade liberalisation paradigm, which protects intellectual property, and asserted the higher priority of the right to health.</p>
<p>In South Africa the TAC <a href="http://www.tac.org.za/documents/MTCTCourtCase/ConCourtJudgmentOrderingMTCTP-5July2002.pdf">successfully challenged</a> the government’s restrictions on access to perinatal treatment before the Constitutional Court. At the international level, the AIDS movement energised the World Health Organisation to take access to medicines seriously. This prompted campaigns such as the World Health Organisation’s <a href="http://www.who.int/3by5/en/">3 by 5</a> initiative. It forced the World Trade Organisation to change course, introducing Doha Declaration <a href="https://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm">flexibilities</a> to soften a harsh intellectual property regime.</p>
<h2>A global effort</h2>
<p>This social mobilisation also unleashed unprecedented resources in global health — new funding for biomedical research, vaccines, and treatment. Moreover, social mobilisation around AIDS literally transformed global health governance. It fundamentally altered the foreign assistance of the most powerful countries. For example PEPFAR in the United States, and <a href="http://www.unitaid.eu/en/">UNITAID</a>, formed by Brazil, Chile, France, Norway, and the United Kingdom. </p>
<p>For the first time, the major powers began to frame an infectious disease as a national security threat, addressed at the highest political levels at the G8. Social mobilisation drove the United Nations’ response, prompting the first high-level summit ever held on a health issue to be devoted to AIDS.</p>
<p>A novel public-private-partnership emerged, outside the UN/WHO structure, to generate and pool resources — the Global Fund to Fight AIDS, Tuberculosis and Malaria.</p>
<p>Although the international community has rallied to fight AIDS, fierce debates have raged within the movement. Initially, advocates worried that traditional public health strategies such as testing and reporting would undermine privacy or foster discrimination. At the same time, policy makers debated which interventions — and in what combination — were most effective. And then there was the divisive issue of cost-effectiveness. Could governments afford expensive interventions such as lifetime treatment with antiretrovirals? </p>
<p>If not, how could the benefits be fairly allocated among the large population of persons at risk or living with HIV? And should the same level of resources devoted to AIDS be made equally available for other pressing health conditions, such as child/maternal health, injuries, or non-communicable diseases? </p>
<p>These battles ensued within both domestic health sectors and foreign health assistance budget debates. They remain topics of lively debate.</p>
<p><em>*This is the first of three articles drawn from the book <a href="http://www.hup.harvard.edu/catalog.php?isbn=9780674728844.">Global Health Law</a>, released by Professor Lawrence Gostin.</em></p><img src="https://counter.theconversation.com/content/54393/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lawrence O. Gostin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Globally, the health community is moving to a point where there could be zero new HIV infections or deaths. But it has been a long road.Lawrence O. Gostin, Professor of Global Health and Director, O'Neill Institute, Georgetown UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/525392015-12-21T05:12:59Z2015-12-21T05:12:59ZHow a drug can help prevent 5000 girls being infected with HIV every week<figure><img src="https://images.theconversation.com/files/106634/original/image-20151218-27887-fle144.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The WHO has recommended pre-exposure prophylaxis, or PrEP, as an additional HIV prevention choice for people with a high risk of being infected. Truvada has been licensed in South Africa.</span> <span class="attribution"><span class="source"> Epa/Maurizio Gambarini</span></span></figcaption></figure><p>South Africa has became one of the first African countries to <a href="http://www.mccza.com/documents/2e4b3a5310.11_Media_release_ARV_FDC_PrEP_Nov15_v1.pdf">license</a> a fixed-dose combination of anti-retrovirals to be used as an oral pre-exposure prophylaxis.</p>
<p>Pre-exposure prophylaxis, more commonly referred to as PrEP, is the use of anti-retroviral drugs by people who do not have HIV to prevent them from becoming infected. The World Health Organisation recently <a href="http://apps.who.int/iris/bitstream/10665/197906/1/WHO_HIV_2015.48_eng.pdf">recommended</a> it as an additional HIV prevention choice for people with a high risk of being infected. </p>
<p>The recommendations are based on <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1011205">studies</a> showing that daily doses of the drug effectively reduce the HIV risk in men and women. This was irrespective of age, mode of HIV transmission or the drug regimen used. The only common factor in the level of protection was how well people adhered to the drug regimens. </p>
<p>The studies also showed that pre-exposure prophylaxis is safe to use in healthy populations as there was no evidence of increased side effects in trial participants.</p>
<h2>Breaking a new frontier</h2>
<p>South Africa’s Medicines Control Council has <a href="http://www.mccza.com/documents/2e4b3a5310.11_Media_release_ARV_FDC_PrEP_Nov15_v1.pdf">ruled</a> that the drug Tenofovir disoproxil/emtricitabine (TDF/FT3), more commonly referred to as Truvada, is safe and effective for use as pre-exposure prophylaxis in the country. This paves the way for the government to issue a tender to procure the drug.</p>
<p>South Africa’s license is incredibly important for HIV prevention in the country as well as the region. It is a critical step to including pre-exposure prophylaxis in publicly-funded HIV prevention programmes. The licensing also means that other countries in the region are likely to follow. </p>
<p>Several policy, programme and procurement processes need to be followed before the drug can be distributed through the healthcare system.</p>
<p>The government is likely to start with pilot sites as it did with anti-retrovirals given to mothers to prevent mother to child transmission. This will help it learn:</p>
<ul>
<li><p>how to identify populations who need and want to use PrEP, </p></li>
<li><p>what systems are needed for delivery, and </p></li>
<li><p>how best to monitor health so that it doesn’t overburden the health service.</p></li>
</ul>
<h2>A solution for young women</h2>
<p>One of the critical steps in developing programmes is defining who will most likely benefit from them. Mathematical models suggest that it is likely to be cost-effective in settings where there are three new infections in every 100 people each year. </p>
<p>In Africa, the populations that have been prioritised to date are sex workers, men who have sex with men and couples where one partner is HIV infected and the other is not. </p>
<p>But research shows that unless HIV prevention in teenage girls and young women is prioritised, the ambitious <a href="http://www.unaids.org/en/resources/campaigns/World-AIDS-Day-Report-2014">targets</a> set by UNAIDS to end HIV by 2030 will not happen. </p>
<p>Every week more than 5000 adolescent girls and young women acquire <a href="http://www.unaids.org/en/resources/campaigns/2014/2014gapreport/gapreport">HIV</a>. And the vast majority of them live in southern Africa. Young women are up to eight times more likely to be infected than their male peers of the same age in eastern and southern Africa. This is despite the rate of new HIV infections <a href="http://www.unaids.org/en/resources/campaigns/HowAIDSchangedeverything/factsheet">declining or stabilising</a> in many other populations. </p>
<p>And although their HIV risk is driven in part by individual behaviour, other factors also play a role. These include:</p>
<ul>
<li><p>poverty, </p></li>
<li><p>gender inequality and high exposure to violence, </p></li>
<li><p>limited economic options, and </p></li>
<li><p>the low social power of young people. </p></li>
</ul>
<h2>Adherence pitfalls</h2>
<p>For PrEP to be effective, it will need to be integrated into existing HIV prevention services. </p>
<p>People at high risk for infection and who wish to start PrEP will need to be tested for HIV before they start and then every three months while taking the drugs. This will ensure that those with an early HIV infection are detected and don’t develop anti-retroviral drug resistance. They will also have their kidney function tested as Truvada can cause <a href="http://www.aidsmap.com/iTruvadai-PrEP-does-not-harm-the-kidneys-trial-shows/page/2827796/">kidney problems</a> in some people.</p>
<p>But the biggest challenge is ensuring that young people, particularly young women, who start PrEP take the pills daily as required. Those taking PrEP daily cannot miss a single dose. While two trials of pre-exposure prophylaxis in South Africa, Zimbabwe, Tanzania, Kenya and Uganda <a href="https://theconversation.com/what-drove-women-to-lie-in-an-hiv-clinical-trial-in-southern-africa-51143">raised questions</a> about whether young women will adhere to pre-exposure prophylaxis, recent open-label studies have shown that when populations at-risk, including young <a href="http://www.hptn.org/web%20documents/HPTN067/HPTN067_SAresults_Fact%20Sheet_V1.0.pdf">women</a>, recognise their risk and know that pre-exposure prophylaxis is effective in preventing HIV, they are able to use it effectively. </p>
<h2>It’s time to implement</h2>
<p>Several pre-exposure prophylaxis demonstration projects are either underway or are being planned across southern and eastern Africa. These projects will inform the development of national policies and programmes, adding to the evidence base to understand how best to innovate, integrate and implement Truvada within a combination HIV prevention package. </p>
<p>The challenges of delivery will only be truly understood through implementing delivery projects. Once we have gained insights into the challenges, we will be able to refine an HIV combination prevention programme to meet the needs and preferences of teenage and young women.</p><img src="https://counter.theconversation.com/content/52539/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sinead Delany-Moretlwe receives funding from USAID/PEPFAR, DFID, and NIH</span></em></p><p class="fine-print"><em><span>Deborah Baron receives funding from DFID and USAID/PEPFAR. </span></em></p>Young women in southern Africa are most at risk of becoming infected with HIV. If they take a pre-exposure prophylaxis like Truvada it could change their lives.Sinead Delany-Moretlwe, Associate Professor and Director: Research at the Wits Reproductive Health and HIV Institute I, University of the WitwatersrandDeborah Baron, Researcher and Programme Manager: Clinical Research Consortium for Wits Reproductive Health and HIV Institute (RHI), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.